Failure to Update and Implement Comprehensive ADL Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all aspects of a resident's activities of daily living (ADL) self-care performance. Record review showed that the resident had severely impaired cognition and required varying levels of assistance for multiple ADLs, including eating, hygiene, dressing, mobility, and transfers. However, the care plan did not include a specific focus area or interventions for the resident's ADL self-care needs, such as how to assist with transfers, bed mobility, or eating. Staff interviews confirmed that the care plan lacked detailed instructions for these tasks, and staff relied on verbal communication or the Kardex for guidance, which sometimes led to inconsistencies in care. The absence of updated and detailed care plan interventions for the resident's ADL needs was acknowledged by the ADON, MDS nurse, and DON, who all indicated that the care plan should have included this information to guide staff in providing appropriate care. The facility's policy required that qualified staff be notified of their roles and responsibilities for carrying out care plan interventions, both initially and when changes occurred, but this was not followed in the case of this resident. As a result, the resident's care plan did not reflect their current needs as identified in the comprehensive assessment.